A study on socio-demographic and obstetric profile, contraceptive use and reasons for medical termination of pregnancy among women attending medical termination of pregnancy clinic in Purba Medinipur district of West Bengal, India

INTRODUCTION

In India, many females die due to pregnancy and related complications despite the efforts of government to reduce maternal mortality through various schemes and facilities. With the legislation of the medical termination of pregnancy (MTP) Act in 1971, India became one of the first countries legalizing abortion on moderately liberal grounds-particularly “failure of contraceptive use” for termination of pregnancies. But unsafe abortion is among the leading causes of maternal mortality and morbidity in India. Many of the females are not aware of the legal and safe abortion facilities, and many of them are forced to seek unsafe abortions for cultural reasons. Apprehension, denial and ignorance to contraceptive usage leads to unwanted pregnancies which are terminated in unhygienic and unsafe conditions by untrained personnel leading to maternal mortality and morbidity. Abortions are usually categorized as spontaneous abortion and induced abortion. Spontaneous abortions occur once in every 15 pregnancies. On the other hand, induced abortions are deliberately induced, they may be legal or illegal. The actual incidence of abortion estimated worldwide, ranges from 30-55 million a year or about 40-70 per 1000 women of reproductive age, with an abortion ratio of 260-450 per 1000 live births. More than 18 million induced abortions each year are performed by people lacking the necessary skills or in an environment lacking the minimal medical standards or both.¹ It is unfortunate that women continue to face severe complications which are totally preventable through just ensuring easy access to safe abortion services.

In India, it has been computed that about 6 million abortions take place every year, of which 4 million are induced and 2 million are spontaneous. Since abortion has been legalized, the number of legal and registered induced abortions has been increasing steadily.² The main causes of maternal mortality in India are hemorrhages (38.0%), infection (11%), unsafe abortion (8.0%), hypertensive diseases (5%), and others (33%).³ Unsafe abortions constitute about 13% of the maternal deaths.⁴ Unsafe abortion is a preventable cause of maternal morbidity and mortality. MTP is generally safe during the first trimester of the pregnancy. According to 2008 global estimates nearly half (48%) of the unintended pregnancies will end in abortion, and most of them will be unsafe.⁵ MTP is done to get rid of unwanted pregnancies and such pregnancies which may be harmful. Several factors contribute to women opting for abortion outside the accredited abortion centers.⁶ The MTP act recognizes the importance of providing safe, affordable, accessible and acceptable abortion services to women who need to terminate an unwanted pregnancy.

The objectives of this study were to study the socio-demographic and obstetric profile and contraceptive use of the mother’s seeking abortion in selected hospitals of Purba Medinipur district as well as to identify the causes for seeking abortion.

METHODS

Study area

The study was conducted in Purba Medinipur district, West Bengal; India.

Study type

The study was of cross-sectional study.

Study design

A cross-sectional study conducted in selected hospitals of Purba Medinipur district of West Bengal.

Study setting

The study was conducted in two hospitals, Tamluk district hospital and Haldia sub-divisional hospital (SDH) of Purba Medinipur district of West Bengal where MTP service was available.

Study population

All women attending the post-partum unit and obstetric clinic of the selected hospitals for MTP services during the study period.

Sampling procedure

Among four tertiary care hospitals in Purba Medinipur district where MTP service is available, 2 hospitals (50%) were selected randomly i.e., Tamluk district hospital and Haldia sub-divisional hospital (SDH).

Sampling technique

Random sampling technique for selection of hospitals.

Sample size

All 52 women attending the post-partum unit and obstetric clinic seeking abortion during the study period were included in the study. The 37 women were selected from Tamluk district hospital and 15 women were selected from Haldia sub divisional hospital (SDH).

Study duration

The study was carried out for 6 months.

Inclusion criteria

All women attending the post-partum unit and obstetric clinic seeking abortion during the study period and giving informed consent were included in the study.

Data collection

Data collected by the investigator by using semi-structured pre-designed and pretested questionnaires which included questions regarding the socio-demographic and contraceptive use of these women, cause of seeking MTP services, history of use of contraceptives etc.

Ethical clearance

Institutional ethical clearance was obtained before the initiation of the study.

RESULTS

A total of 52 women participated in the study as the study subjects in this study. Most of them were between 26-35 years of age (53.84%) followed by 34.61% of the women who were between 18-25 years of age. 88.46% of women were Hindu by religion and most of them belonged to nuclear families (80.76%). Most of the women (48.07%) were having secondary education.

The 32.69% had primary education, 9.61% was just literate (They can only sign their own name) but only 7.69% had higher secondary education. Majority of women were housewives (67.30%) and 23.07% were daily wage earner. 98.07% women were married and from rural area (86.53%) (Table 1).

The 76.92% women were seeking MTP were below 12 weeks of gestation and remaining 23.07% of women were in 12-20 weeks of gestation. The 7.69% had history of previous MTP. Out of 52 women studied, who underwent MTP 55.76% had 2 living children, 28.84% had 1 living child, 3.84% had 3 living children, 5.76% had more than 3 living children and 5.76% had no living children. About 26.92% women had their first pregnancy before 18 years of age, 69.23% had their first pregnancy within 18-25 years of age and only 3.84% had their first pregnancy within 26-35 years of age (Table 2).

Out of 52 women, 4 women had a history of previous MTP. The 50% of previous MTPs were done by quack and remaining 50% were done in private and government hospital respectively (Table 3).

Out of 52 participants only 48.07% used any contraception methods and 51.92% were not using any methods. Majority of them were OCP users (19.23%) followed by were IUCD users (15.38%) and only 13.46% of women stated that their husband used condoms (Table 4).

Major cause of non-use of any contraception as stated by the study subjects were husband stays away (19.23%), fear of side effects (17.30%), family pressure (7.69%) and does not want to use (7.6%) (Table 5).

Common reasons given by the mother for terminating pregnancy were previous baby too young (32.69%), completed family size (28.84%), contraceptive failure (28.84%), economic reasons (7.69%) and undergoing studies as student (1.92%) (Figure 1).

Majority of the women (98.06%) accepted post abortion contraception. Of these, 9.61% women accepted copper-T, 44.23% accepted OCPs, 3.84% accepted DMPA and 40.38% accepted permanent sterilization method respectively (Figure 2).

DISCUSSION

The current study was conducted to assess socio-demographic profile and reasons for medical termination of pregnancy among women attending MTP clinic. Most of the women (53.84%) were between 26-35 years of age and belonged to Hindu (88.46%) nuclear families (80.76%). Majority of the women (48.07%) had secondary level of education and 32.69% had primary level of education. Majority of them were married (86.53%), housewives (67.30%) and from rural area in an observational study conducted by Sharma et al in the outpatient clinic of OBG department of SGRR medical college, Dehradun, Uttarakhand, India in 2013 found that 56.8% women were in the age group of 26-35 years and 78.44% women belonged to Hindu religion. In that study 81.89% women were housewives and 75.8% women had parity of more than two.⁷

Similarly, Ganguli et al in their study on profile of women undergoing medical termination of pregnancy in hospital, found that 44.4% MTP seekers were illiterate, 48.2% cases were educated up to primary school and only 7.3% cases up to high school and above.⁸

In this study it was found that majority of the women (76.92%) were seeking MTP within 12 weeks of pregnancy. Only 4 (7.69%) had history of previous MTP. It was also revealed in the present study that 69.23% had their first pregnancy within 18-25 years of age. There is a need to make the women aware of the various contraceptive measures available free of cost from any government health facility.

In this study 55.76% of the study population had 2 living children, 28.84% had 1 living child, 3.84% had 3 living children, 5.76% had more than 3 living children and 5.76% had no living children. Ram et al in their study on unmet need for family planning among married women in Calcutta reported that 31% women had 2 or less children while 69% had more than 2 children.⁹ Padhy reported that 30% had 2 or less children in their study on attitude of women towards family planning in an urban area of Orissa.¹⁰

In this study 4 women had a history of previous MTP. The 50% of previous MTPs were done by quack and remaining 50% were done in private and government hospital respectively. Dhillon et al in their study in 13 states of India found that the most common place for abortion was “private clinic” (45.6%). Other places included “hospital” (37.1%), public health center (PHC)/ community health center (14.0%).¹¹

In this study most common reason as stated by the mother for terminating the pregnancy was previous baby too young (32.69%). Other reasons given were, completed family size (28.84%), contraceptive failure (28.84%), Economic reasons (7.69%) and undergoing studies as student (1.92%). In Shivakumar et al the most common reason behind abortion was unplanned pregnancy (30.7%) followed by contraceptive failure (29.3%).¹² Bahadur et al cited termination of unplanned pregnancy (32.8%) as the most common reason, inadequate income in 24.6%, contraceptive failure in 22.3% and family complete in 20.3% women.¹³

In the present study, contraception was practiced by 48.07% of the respondents. Majority of them (19.23%) were OCP users.15.38% were IUCD (CU-T) users and 13.46%women stated that their husband used condoms. About 51.92% of women were not using any methods of contraception and did not have any desire to conceive reflecting the unmet need of contraception.

In this study the major cause of non-use of any contraception was due to husband stays away (19.23%) and fear of side effects (17.30%). According to a cross sectional study conducted by Battathiry et al in urban Tamil-Nadu the prevalence of unmet need for FP was found to be 39%, with spacing as 12% and limiting as 27%. The major reason for unmet need for family planning was 18% for low perceived risk of pregnancy, 9% feared the side effects of contraception, 5% lacked information on contraceptives, 4% had husbands who opposed it and 3% gave medical reasons.¹⁴ In the present study majority of the women (98.06%) accepted post abortion contraception. Of these, 9.61% women accepted copper-T, 44.23% accepted OCPs, 3.84% accepted DMPA and 40.38% accepted permanent sterilization method respectively.

By the depth interview with the beneficiaries and the health care providers it was found in the present study that the study subjects require more health-related education and proper awareness about abortion services. Many of the study subjects were not aware of the legal and safe abortion facilities. It is unfortunate that women continue to face severe complications which are totally preventable through just ensuring easy access to safe abortion services. These services were hampered because of COVID-19 situation due to restricted mobility and many of the study subjects could not reach the hospitals moreover they were not aware about these MTP services which were available free of cost in the govt. hospitals.

That’s why they went to the quack and private hospitals which were not accredited to deliver these services and often came back with some post abortion related complications. The reasons for less utilization of these services were lack of knowledge, ignorance, lack of motivation of the target population and less prioritization and preoccupation of grass root workers like ASHA and ANM especially during pandemic situation.

Limitations

Ongoing COVID-19 pandemic and time constraints were responsible for a smaller number of study participants. Restricted mobility during lock down period prevented the beneficiaries from visiting the hospitals. Further studies for longer duration could reveal better results.

CONCLUSION

Unsafe abortion is a major public health problem in India. The results indicate that awareness about contraceptives is not sufficient; more efforts are needed to make people aware about contraceptives. Females in the young age group, residing in the rural areas are more vulnerable to unwanted pregnancies and illegal abortions and the unmet need of contraception may be one of the reasons. Eligible couples have to be educated regarding the availability and accessibility of different methods of contraceptives and their proper use to avoid unwanted pregnancy as long as they want and to address unmet need for contraception. Intensive mass awareness campaigns necessary focused towards the target group for increased utilization of the available MTP services, prevention of complications and attainment of desired goals.

Recommendations

Unmet need of contraception is still an issue in respect to unwanted pregnancy. According to WHO women with unmet need are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the next child. The concept of unmet need points to the gap between women's reproductive intentions and their contraceptive behavior.

So, improving the quality of care can reduce unmet need among women by creating demand of contraceptives among new users, preventing attrition among current users, and closing the gap when women are without contraception but do not desire to be pregnant. So focused attention from front line workers like ANM, ASHA is required to meet the unmet need of contraception.

Eligible couples have to be educated regarding the availability and accessibility of MTP services along with different methods of contraceptive and their proper use to avoid pregnancy as long as they want.

ACKNOWLEDGEMENTS

Author would like to thanks to Dr. Asit Kumar Biswas and Dr. Goutam Joardar, Dr. Nitai Chandra Mandal, Dr. Samir Dasgupta, Dr. Bibhash Ray, chief medical officer of health, Purba Medinipur; all the district officials and staff members of health department of Purba Medinipur district and all the participants of my study for extending all possible help and co-operation during the data collection.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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